The more this kind of crap happens the more I wonder whether these collective actions couldn't be contested in federal court. As I understand it, the federal government has a legal obligation to faithfully uphold the laws passed by congress. I'm not a legal expert, but it seems this current congress and executive branch long ago crossed the line of "good faith" towards teh ACA (still the law of the land).

Open question: Can the HHS be sued for actively sabotaging a law such as the ACA? Can the courts compel these offices to act in good faith of the law?

Yes I believe so. Just like the EPA or Department of Defense can be sued for not upholding various laws like the Clean Water Act, etc. I would believe that is the case.

The more this kind of crap happens the more I wonder whether these collective actions couldn't be contested in federal court. As I understand it, the federal government has a legal obligation to faithfully uphold the laws passed by congress. I'm not a legal expert, but it seems this current congress and executive branch long ago crossed the line of "good faith" towards teh ACA (still the law of the land).

Open question: Can the HHS be sued for actively sabotaging a law such as the ACA? Can the courts compel these offices to act in good faith of the law?

Some group like ACLU would have to find a test case of someone who is directly harmed by this sabotage. Then, they have to take it all the way through the appeals process to the Supreme Court. Then the Supreme Court, itself a somewhat conservative institution these days due to the Gorsuch nomination, would have to agree to take up the case and find in favor of the plaintiff. Finding the right test case is extremely important.

After that whole years-long process you still have the problem of the administration actually abiding by the decision. With everything else that's going on that's actually somewhat of an open question.

The more this kind of crap happens the more I wonder whether these collective actions couldn't be contested in federal court. As I understand it, the federal government has a legal obligation to faithfully uphold the laws passed by congress. I'm not a legal expert, but it seems this current congress and executive branch long ago crossed the line of "good faith" towards teh ACA (still the law of the land).

Open question: Can the HHS be sued for actively sabotaging a law such as the ACA? Can the courts compel these offices to act in good faith of the law?

Some group like ACLU would have to find a test case of someone who is directly harmed by this sabotage. Then, they have to take it all the way through the appeals process to the Supreme Court. Then the Supreme Court, itself a somewhat conservative institution these days due to the Gorsuch nomination, would have to agree to take up the case and find in favor of the plaintiff. Finding the right test case is extremely important.

After that whole years-long process you still have the problem of the administration actually abiding by the decision. With everything else that's going on that's actually somewhat of an open question.

yeah, the whole "duty/breach/cause/harm" paradigm. I understand that relying on the courts could take years and that the upper courts may refuse to hear it - especially if the law gets changed during the interium, under the argument that any decision no longer holds relevance (under a new hypothetical law).Shouldn't be too hard to find a good test case though; active sabotage is going to leave thousands without insurance, and certainly some of them will experience physical and financial harm from being uninsured when they ought to have been covered.

The more this kind of crap happens the more I wonder whether these collective actions couldn't be contested in federal court. As I understand it, the federal government has a legal obligation to faithfully uphold the laws passed by congress. I'm not a legal expert, but it seems this current congress and executive branch long ago crossed the line of "good faith" towards teh ACA (still the law of the land).

Open question: Can the HHS be sued for actively sabotaging a law such as the ACA? Can the courts compel these offices to act in good faith of the law?

Some group like ACLU would have to find a test case of someone who is directly harmed by this sabotage. Then, they have to take it all the way through the appeals process to the Supreme Court. Then the Supreme Court, itself a somewhat conservative institution these days due to the Gorsuch nomination, would have to agree to take up the case and find in favor of the plaintiff. Finding the right test case is extremely important.

After that whole years-long process you still have the problem of the administration actually abiding by the decision. With everything else that's going on that's actually somewhat of an open question.

yeah, the whole "duty/breach/cause/harm" paradigm. I understand that relying on the courts could take years and that the upper courts may refuse to hear it - especially if the law gets changed during the interium, under the argument that any decision no longer holds relevance (under a new hypothetical law).Shouldn't be too hard to find a good test case though; active sabotage is going to leave thousands without insurance, and certainly some of them will experience physical and financial harm from being uninsured when they ought to have been covered.

I don't know, the muslim ban didn't take very long to work its way through the courts. Although it isn't resolved yet, the supremes did lift part of the lower court injunction until it comes up in their queue for a final decision. Seems like things can move pretty fast when they involve a hot enough political issue.

Who is "we?" Currently we (My wife and I) pay our medicare tax, our insurance premiums, and any healthcare we incur which so far has been below our yearly deductible. Last couple of years, roughly our family spent $13k/yr which is pretty damn low since we are young and healthy. How much more will we have to pay to help cover the rest of the US? Maybe I am just not getting the math. I'm sure you will agree that we will have to pay more. How much more?

If the cost of healthcare on average is $10,500/person we are definitely underpaying our share of the average. Someone else must be covering our share as well as covering all those people who pay less or nothing at all. Who are these people? I have to be missing something, what is it?

Don't forget you are also paying through your general taxes, thanks to the very generous tax breaks given to employer-provided healthcare spending, which adds up to a huge amount of lost revenue that must be made up somewhere. Also remember that everybody pays to offset those tax breaks while not everybody is lucky enough to have the benefit of health insurance via their employer, ironically meaning that poorer people are in a way paying for a benefit that mostly only middleclass and up enjoys.

Thanks for the information Ocelot, the above as well as your explanation about insurance profits are actually less than 20%. The does lead me into more questions. Since under a universal healthcare plan business will not be offering health insurance as a benefit. Do you think we will get raises to help offset some of the tax hike on healthcare or will businesses just take the decreased expense for themselves?

I am not a fan of our current healthcare system but as a higher income earner very concerned about my taxes going up "significantly" in a universal healthcare plan. I can afford paying a bit more and would not mind it too much if it had a worthwhile benefit. More importantly I am very concerned for middle class Americans who currently pay for healthcare will find their taxes go up significantly to help fund universal healthcare. I think this is the same group of people who are getting squeezed by the ACA. They make too much money for subsidies and now also need to pay higher premiums and deductibles as compared to before the ACA.

So what do you think? How much will a family of 4 making lets say $120k/yr have to pay in taxes to pay for healthcare for themselves and also help fund it for all Americans taking into account that we spend $10,500/person/yr and you expect US citizens to pay a little less if we remove the insurance profit?

Who is "we?" Currently we (My wife and I) pay our medicare tax, our insurance premiums, and any healthcare we incur which so far has been below our yearly deductible. Last couple of years, roughly our family spent $13k/yr which is pretty damn low since we are young and healthy. How much more will we have to pay to help cover the rest of the US? Maybe I am just not getting the math. I'm sure you will agree that we will have to pay more. How much more?

If the cost of healthcare on average is $10,500/person we are definitely underpaying our share of the average. Someone else must be covering our share as well as covering all those people who pay less or nothing at all. Who are these people? I have to be missing something, what is it?

Why are you sure of this? The fundamental problem is we, as a collective nation, spend FAR more money than should be necessary on health care. If we lower what we pay as a collective, why do you insist that individual costs are going to skyrocket?

Exactly, now I think you are getting to the real problem of healthcare in the US. We pay toooooo much and very few talk about how to decrease costs. We spend lots of time talking about who will pay. The rich, the poor, or the middle class. But who is talking about decreasing cost? Who is talking about letting CMS negotiate prices? Who is talking about decreasing some of the bureaucracy involved in delivering healthcare in the US?

My personal opinion is that we will be seeing very little change in the US until costs becomes so astronomical that we will have no choice but to ignore the lobbyists and actually make laws that decrease how much we pay.

BTW, your link above was very cool, but I do not think it addresses my question on how much will upper middle class Americans have to pay for universal healthcare?

My personal opinion is that we will be seeing very little change in the US until costs becomes so astronomical that we will have no choice but to ignore the lobbyists and actually make laws that decrease how much we pay.

LOL, I used to think we were close to that point back in the '90s. Little did I know.

"The White House is finalizing an executive order that would expand health plans offered by associations to allow individuals to pool together and buy insurance outside their states..."

"Under the president's executive action, membership groups could sponsor insurance plans that cost less because — for example — they wouldn't have to offer the full menu of benefits required under the Affordable Care Act, also called "Obamacare." It's unclear how the White House plans to overcome opposition from state insurance regulators, who see that as an end-run to avoid standards."

Who is "we?" Currently we (My wife and I) pay our medicare tax, our insurance premiums, and any healthcare we incur which so far has been below our yearly deductible. Last couple of years, roughly our family spent $13k/yr which is pretty damn low since we are young and healthy. How much more will we have to pay to help cover the rest of the US? Maybe I am just not getting the math. I'm sure you will agree that we will have to pay more. How much more?

If the cost of healthcare on average is $10,500/person we are definitely underpaying our share of the average. Someone else must be covering our share as well as covering all those people who pay less or nothing at all. Who are these people? I have to be missing something, what is it?

Why are you sure of this? The fundamental problem is we, as a collective nation, spend FAR more money than should be necessary on health care. If we lower what we pay as a collective, why do you insist that individual costs are going to skyrocket?

Exactly, now I think you are getting to the real problem of healthcare in the US. We pay toooooo much and very few talk about how to decrease costs. We spend lots of time talking about who will pay. The rich, the poor, or the middle class. But who is talking about decreasing cost? Who is talking about letting CMS negotiate prices? Who is talking about decreasing some of the bureaucracy involved in delivering healthcare in the US?

My personal opinion is that we will be seeing very little change in the US until costs becomes so astronomical that we will have no choice but to ignore the lobbyists and actually make laws that decrease how much we pay.

BTW, your link above was very cool, but I do not think it addresses my question on how much will upper middle class Americans have to pay for universal healthcare?

Agree 100%. But a lot of different groups of people benefit from our high costs (doctors, pharma, hospitals, medical suppliers, insurance companies) and they have no interest in seeing things change. EnjoyIt-health care economists have found that a tiny percentage of patients drive 50% of all health care costs. Also, much preventative medicine, even if people followed advice to implement, wouldn't really help that remaining 50% go down much. What do you think can be done to reduce costs? I'd like to see out-of-network balance billing abuse laws passed everywhere, but that is only a small part of the problem.

Who is "we?" Currently we (My wife and I) pay our medicare tax, our insurance premiums, and any healthcare we incur which so far has been below our yearly deductible. Last couple of years, roughly our family spent $13k/yr which is pretty damn low since we are young and healthy. How much more will we have to pay to help cover the rest of the US? Maybe I am just not getting the math. I'm sure you will agree that we will have to pay more. How much more?

If the cost of healthcare on average is $10,500/person we are definitely underpaying our share of the average. Someone else must be covering our share as well as covering all those people who pay less or nothing at all. Who are these people? I have to be missing something, what is it?

Why are you sure of this? The fundamental problem is we, as a collective nation, spend FAR more money than should be necessary on health care. If we lower what we pay as a collective, why do you insist that individual costs are going to skyrocket?

Exactly, now I think you are getting to the real problem of healthcare in the US. We pay toooooo much and very few talk about how to decrease costs. We spend lots of time talking about who will pay. The rich, the poor, or the middle class. But who is talking about decreasing cost? Who is talking about letting CMS negotiate prices? Who is talking about decreasing some of the bureaucracy involved in delivering healthcare in the US?

My personal opinion is that we will be seeing very little change in the US until costs becomes so astronomical that we will have no choice but to ignore the lobbyists and actually make laws that decrease how much we pay.

BTW, your link above was very cool, but I do not think it addresses my question on how much will upper middle class Americans have to pay for universal healthcare?

...you mean other than us here in 74 pages-and-counting of discussion about US health care laws?As Wexler pointed out, health care benefits so many people and a plethora of diverse groups that there's an enormous constituency that doesn't want to see [their] slice of the pie get any smaller. How many times have the headline monthly jobs report been followed by teh sentence "...led by large gains in the health care sector..." For me that's the single biggest argument for single-payer health care and a potential response to your repeated query about whether or not single-payer would reduce costs. It certainly could, and based on other countries if done right it could cut costs by 50% or more.Here's where I think the GOP has hit the height of hypocracy in the last decade or so. Many of these ideas they used to champion, and they used to howl about how expensive the entire system was becoming. Now... they want the opposite, and want all price limiting restrictions stripped from legislation. Seemly because when the other side does it, it must be "bad"

There is of course the seldom talked about downside, that reducing costs will almost by definition result in the loss of hundreds of thousands (if not millions) of jobs. The Kaiser foundation estimates there are 12.5MM people in the health care sector, and that excludes all of the people in the insurance market.

Who is "we?" Currently we (My wife and I) pay our medicare tax, our insurance premiums, and any healthcare we incur which so far has been below our yearly deductible. Last couple of years, roughly our family spent $13k/yr which is pretty damn low since we are young and healthy. How much more will we have to pay to help cover the rest of the US? Maybe I am just not getting the math. I'm sure you will agree that we will have to pay more. How much more?

If the cost of healthcare on average is $10,500/person we are definitely underpaying our share of the average. Someone else must be covering our share as well as covering all those people who pay less or nothing at all. Who are these people? I have to be missing something, what is it?

Why are you sure of this? The fundamental problem is we, as a collective nation, spend FAR more money than should be necessary on health care. If we lower what we pay as a collective, why do you insist that individual costs are going to skyrocket?

Exactly, now I think you are getting to the real problem of healthcare in the US. We pay toooooo much and very few talk about how to decrease costs. We spend lots of time talking about who will pay. The rich, the poor, or the middle class. But who is talking about decreasing cost? Who is talking about letting CMS negotiate prices? Who is talking about decreasing some of the bureaucracy involved in delivering healthcare in the US?

My personal opinion is that we will be seeing very little change in the US until costs becomes so astronomical that we will have no choice but to ignore the lobbyists and actually make laws that decrease how much we pay.

BTW, your link above was very cool, but I do not think it addresses my question on how much will upper middle class Americans have to pay for universal healthcare?

Agree 100%. But a lot of different groups of people benefit from our high costs (doctors, pharma, hospitals, medical suppliers, insurance companies) and they have no interest in seeing things change. EnjoyIt-health care economists have found that a tiny percentage of patients drive 50% of all health care costs. Also, much preventative medicine, even if people followed advice to implement, wouldn't really help that remaining 50% go down much. What do you think can be done to reduce costs? I'd like to see out-of-network balance billing abuse laws passed everywhere, but that is only a small part of the problem.

Everyone in the medical industry has incentive to keep certain pieces of todays structure and change others. Insurance, pharma, and suppliers love the system we have now. Insurance in particular has has record high profits the last few years. Hospitals are hit or miss depending on the location they are in, but they do spend significant capital to meet regulation or benchmarks that have not shown to statistically impact or improve patient care. They also spend significant amounts of capital on dealing with the insurance industry as well as CMS. A singer payer system would definitely decrease the later. Although most physicians make good money, I have yet to meet a doctor who is happy with the current system. Most physicians, myself included are concerned about single payer because they worry wages will go down and bureaucracy will go up.

Regarding your quoted article. Balance billing is a byproduct of poor reimbursement. For example a general surgeon will get paid $300 to remove a gallbladder. That doesn't just include the surgery but also includes post op in hospital re-eval, office re-eval, pre-op evaluation as well as treating any potential complications that may arise from the surgery. From that money the physician has to pay the staff required to bill/collect as well any office staff for pre-op and post of visits. It doesn't matter if the procedure takes 1.5 hours on an easy patient, or 3 hours on a highly inflamed and scared up organ which also increases the risk of complications. I will let you decide if $300 is enough. Every surgeon obviously thinks it is not and therefor some will balance bill when possible. I don't think balance billing for another $200-300 bucks is that big of a deal if explained/negotiated prior to the procedure. I am appalled at how some unscrupulous physicians will balance bill for thousands. The article you linked does not describe every physician but a small fraction of asshats that make the rest of us look bad. And yes it is just one of the things that needs to change in order to decrease the cost of healthcare in the US.

Who is "we?" Currently we (My wife and I) pay our medicare tax, our insurance premiums, and any healthcare we incur which so far has been below our yearly deductible. Last couple of years, roughly our family spent $13k/yr which is pretty damn low since we are young and healthy. How much more will we have to pay to help cover the rest of the US? Maybe I am just not getting the math. I'm sure you will agree that we will have to pay more. How much more?

If the cost of healthcare on average is $10,500/person we are definitely underpaying our share of the average. Someone else must be covering our share as well as covering all those people who pay less or nothing at all. Who are these people? I have to be missing something, what is it?

Why are you sure of this? The fundamental problem is we, as a collective nation, spend FAR more money than should be necessary on health care. If we lower what we pay as a collective, why do you insist that individual costs are going to skyrocket?

Exactly, now I think you are getting to the real problem of healthcare in the US. We pay toooooo much and very few talk about how to decrease costs. We spend lots of time talking about who will pay. The rich, the poor, or the middle class. But who is talking about decreasing cost? Who is talking about letting CMS negotiate prices? Who is talking about decreasing some of the bureaucracy involved in delivering healthcare in the US?

My personal opinion is that we will be seeing very little change in the US until costs becomes so astronomical that we will have no choice but to ignore the lobbyists and actually make laws that decrease how much we pay.

BTW, your link above was very cool, but I do not think it addresses my question on how much will upper middle class Americans have to pay for universal healthcare?

...you mean other than us here in 74 pages-and-counting of discussion about US health care laws?As Wexler pointed out, health care benefits so many people and a plethora of diverse groups that there's an enormous constituency that doesn't want to see [their] slice of the pie get any smaller. How many times have the headline monthly jobs report been followed by teh sentence "...led by large gains in the health care sector..." For me that's the single biggest argument for single-payer health care and a potential response to your repeated query about whether or not single-payer would reduce costs. It certainly could, and based on other countries if done right it could cut costs by 50% or more.Here's where I think the GOP has hit the height of hypocracy in the last decade or so. Many of these ideas they used to champion, and they used to howl about how expensive the entire system was becoming. Now... they want the opposite, and want all price limiting restrictions stripped from legislation. Seemly because when the other side does it, it must be "bad"

There is of course the seldom talked about downside, that reducing costs will almost by definition result in the loss of hundreds of thousands (if not millions) of jobs. The Kaiser foundation estimates there are 12.5MM people in the health care sector, and that excludes all of the people in the insurance market.

To be honest with you, other than my rhetoric and a few comments the 74 pages here talk about how republicans are morons and the poor will suffer. Much of the talk here is about who will be paying for our expensive healthcare. The Republicans want the poor to pay which is idiotic since they are poor and can't afford it. The democrats want the rich and middle class to pay. They say mostly the rich, but the reality is that the middle and upper middle class take a significant hit as well. We did have some nice discussions about CMS negotiating with pharma and we talked about death panels. Outside of this 74 pages the conversation in the political arena is about cost shifting and not cost reduction. That is why I am so pessimistic regarding any real change to our healthcare system.

I would love to see easier accessibility to cheap generic medications, double and quadruple patient rooms for the non resourced patients, removal of benchmarks and regulations that provide no benefit to patient outcomes. I would love to see the insurance middle man eliminated from low cost medical expenses for those with the resources to afford it. Something as simple as refilling a chronic medication involves several people when it should involve the patient, the pharmacist and maybe once or twice a year the doctor who prescribed it. Everyone else is just inefficient waste. There is tons more out there for cost reduction but I have yet to hear a politician discussing them.

BTW, lately I have been seeing examples of medications, or studies actually cost more with insurance as compared to cash payment. Just the other day I saw an MRI cost a patient $750 with insurance, $500 without. The thing is the $500 would not go towards meeting the deductible for the year. Just one more thing to think about in our convoluted health system.

I would love to see easier accessibility to cheap generic medications, double and quadruple patient rooms for the non resourced patients, removal of benchmarks and regulations that provide no benefit to patient outcomes. I would love to see the insurance middle man eliminated from low cost medical expenses for those with the resources to afford it. Something as simple as refilling a chronic medication involves several people when it should involve the patient, the pharmacist and maybe once or twice a year the doctor who prescribed it. Everyone else is just inefficient waste. There is tons more out there for cost reduction but I have yet to hear a politician discussing them.

BTW, lately I have been seeing examples of medications, or studies actually cost more with insurance as compared to cash payment. Just the other day I saw an MRI cost a patient $750 with insurance, $500 without. The thing is the $500 would not go towards meeting the deductible for the year. Just one more thing to think about in our convoluted health system.

Regarding drugs, lets do a case study. One very disturbing trend I see firsthand is the ridiculous price trends of insulin...which millions of people are dependent on and absolutely cannot live without.

"According to the lawsuit, the list price of Lilly’s drug, called Humalog, has doubled in the past five years. In the mid-‘90s, when the drug was first launched, it cost $21 a vial. Now, list price for that same amount is $274."

Now multiply that by millions of people who are totally dependent on it...and you get the idea of the big money involved. And again there are no 'generic' forms of insulin at all.

We see this firsthand as we have a family member that uses Humalog. The price increases have been outrageous but at least it is covered well if you have insurance. These are the sorts of things that have to be dealt with if we ever want to see healthcare costs 'trend down'.

As an aside, I can see why some drugs are expensive...as it does cost a tremendous amount to create niche cancer drugs and such. However, it really does seem proper to somehow regulate drugs that have been established for decades where an equivalent generic doesn't exist ( insulin being a prime example )

I would love to see easier accessibility to cheap generic medications, double and quadruple patient rooms for the non resourced patients, removal of benchmarks and regulations that provide no benefit to patient outcomes. I would love to see the insurance middle man eliminated from low cost medical expenses for those with the resources to afford it. Something as simple as refilling a chronic medication involves several people when it should involve the patient, the pharmacist and maybe once or twice a year the doctor who prescribed it. Everyone else is just inefficient waste. There is tons more out there for cost reduction but I have yet to hear a politician discussing them.

BTW, lately I have been seeing examples of medications, or studies actually cost more with insurance as compared to cash payment. Just the other day I saw an MRI cost a patient $750 with insurance, $500 without. The thing is the $500 would not go towards meeting the deductible for the year. Just one more thing to think about in our convoluted health system.

Regarding drugs, lets do a case study. One very disturbing trend I see firsthand is the ridiculous price trends of insulin...which millions of people are dependent on and absolutely cannot live without.

"According to the lawsuit, the list price of Lilly’s drug, called Humalog, has doubled in the past five years. In the mid-‘90s, when the drug was first launched, it cost $21 a vial. Now, list price for that same amount is $274."

Now multiply that by millions of people who are totally dependent on it...and you get the idea of the big money involved. And again there are no 'generic' forms of insulin at all.

We see this firsthand as we have a family member that uses Humalog. The price increases have been outrageous but at least it is covered well if you have insurance. These are the sorts of things that have to be dealt with if we ever want to see healthcare costs 'trend down'.

As an aside, I can see why some drugs are expensive...as it does cost a tremendous amount to create niche cancer drugs and such. However, it really does seem proper to somehow regulate drugs that have been established for decades where an equivalent generic doesn't exist ( insulin being a prime example )

Just look at what Mylan did when they acquired rights to EpiPen in 2007.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

I think salaries are a very big part of the fundamental problem that our health care costs too damn much per person. The counterargument for why physicians, parituclarly specialists, sohuld be compensated so highly are the factors you mention (extensive schooling, training, hours) in addition to the huge cost of going to medical school in teh first place. If we addressed how much it cost to go ot medical school physicians' salaries could be reduced substantially. Our current psuedo-free makret approach leads to more people choosing highly specialized fields (rather than primary care) precisely because the 'trade-off' is worth the extra couple years of residency when the up-front financial burden (med-school) is so great and the increased end payoff (extermely high salary) is several times larger.

It's worth noting that many other developed countries have similar trainning requirements (4 years of medical school + residency) and doctor's salaries are 30-50% less, but the patient outcome is remarkably similar. Eliminate or reduce the up-front medical school debt and address the insane working hours (particulary for residents) and we could have doctors who make a more healthy and wel compensated living on $80-125k/year.

I think salaries are a very big part of the fundamental problem that our health care costs too damn much per person. The counterargument for why physicians, parituclarly specialists, sohuld be compensated so highly are the factors you mention (extensive schooling, training, hours) in addition to the huge cost of going to medical school in teh first place. If we addressed how much it cost to go ot medical school physicians' salaries could be reduced substantially. Our current psuedo-free makret approach leads to more people choosing highly specialized fields (rather than primary care) precisely because the 'trade-off' is worth the extra couple years of residency when the up-front financial burden (med-school) is so great and the increased end payoff (extermely high salary) is several times larger.

It's worth noting that many other developed countries have similar trainning requirements (4 years of medical school + residency) and doctor's salaries are 30-50% less, but the patient outcome is remarkably similar. Eliminate or reduce the up-front medical school debt and address the insane working hours (particulary for residents) and we could have doctors who make a more healthy and wel compensated living on $80-125k/year.

I don't disagree with anything you've said, but now we have to drill another level deeper and figure out (1) why medical school costs so much, and (2) why the insane working hours exist. I haven't researched it, but I'm wondering if med schools are experiencing the same kind of price inflation that is going on at most institutions of higher learning. If so, that means we need to take a hard look at eliminating the ballooning layers of non-instructor administration, and controlling inflated salaries in the administration that remains. I don't have a clue about the insane working hours - maybe one of the physicians who have been participating in this thread could enlighten us.

It's much more than that. 20+ years ago, I worked for an estate planning lawyer. One of his clients was a cardiologist making $800,000 a year. Back in the early 1990s.

Anyway, another issue with our system here is how many expensive specialists we have and how often we see them. Countries that keep their medical costs care down rely a lot more on primary physicians. Think about how NHS operates and the ratio of GPs to consultants.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

I think salaries are a very big part of the fundamental problem that our health care costs too damn much per person. The counterargument for why physicians, parituclarly specialists, sohuld be compensated so highly are the factors you mention (extensive schooling, training, hours) in addition to the huge cost of going to medical school in teh first place. If we addressed how much it cost to go ot medical school physicians' salaries could be reduced substantially. Our current psuedo-free makret approach leads to more people choosing highly specialized fields (rather than primary care) precisely because the 'trade-off' is worth the extra couple years of residency when the up-front financial burden (med-school) is so great and the increased end payoff (extermely high salary) is several times larger.

It's worth noting that many other developed countries have similar trainning requirements (4 years of medical school + residency) and doctor's salaries are 30-50% less, but the patient outcome is remarkably similar. Eliminate or reduce the up-front medical school debt and address the insane working hours (particulary for residents) and we could have doctors who make a more healthy and wel compensated living on $80-125k/year.

I had an interesting observation this summer when our daughter visited a former exchange student friend in Argentina ( tip : if your kid wants to travel the world...tell them to get to know the exchange students! ).

Anyway, the mother of this friend is an ER surgeon. However, they live what we would call a 'middle class' life. They live in a small two bedroom apartment, etc... Nothing extravagant at all. In fact the average physician salary in argentina is only around 40K USD. On the other hand, medical training is top notch..and very low cost for the individual. And they are actually working to control medical costs...imagine that.

So expectations will need to change if we ever go the 'socialized medicine single payer' route. This will be a tough nut to crack. First of all, our entire system of medical training will have to change. Most medical students go into incredible debt...and even worse debt for specialist training. However, they easily pay that back due to the expectation of large salaries, etc... And by looking at the homes and lifestyles of many doctors around here, they are doing incredibly well ( we live at the home of the Mayo Clinic ).

No good answers here ( and I'm not sure there are any)..but I just wanted to share this personal observation.

Most medical students go into incredible debt...and even worse debt for specialist training. However, they easily pay that back due to the expectation of large salaries

I don't see this as any different from any other market bubble. Real estate prices are so high because rents are so high! Salaries are so high because profits are so high! Gold is so high because everyone is buying it! It will pop eventually, and not just for doctors. All higher education has to come down in relative price.

And in an interesting twist that is rarely mentioned around these parts, the solution to this thread's problem is already being discussed in other threads: more immigration. Those top notch doctors from Argentina, or Canada, or the UK will work for normal middle class salaries. They are what we need to bring down health care costs in America. Wildly unrestricted immigration policies for anyone with an MD would be a good start. Let's import some of that foreign talent.

Restrictive immigration policies are part of the reason why American healthcare costs so much. We pay our doctors too much, in part because American medical training costs so much. But it's not a chicken-and-egg problem, because we already have access to millions of highly trained (on someone else's dime) medical professionals who desperately want to move to America and work for half of the typical US doctor's wage. All we have to do is stop refusing them permission to immigrate.

...And in an interesting twist that is rarely mentioned around these parts, the solution to this thread's problem is already being discussed in other threads: more immigration. Those top notch doctors from Argentina, or Canada, or the UK will work for normal middle class salaries. They are what we need to bring down health care costs in America. Wildly unrestricted immigration policies for anyone with an MD would be a good start. Let's import some of that foreign talent.

Restrictive immigration policies are part of the reason why American healthcare costs so much. We pay our doctors too much, in part because American medical training costs so much. But it's not a chicken-and-egg problem, because we already have access to millions of highly trained (on someone else's dime) medical professionals who desperately want to move to America and work for half of the typical US doctor's wage. All we have to do is stop refusing them permission to immigrate.

Immigration could certainly lower costs here, but the doctors and their lobbies have put up the mother of all protective moats. You cannot be a trained doctor in, say, the UK (or Canada!), move to the US and continue practicing as a doctor right away. In most cases it takes several years to become board-certified should your medical degree come from another country, even when everyone openly admits that your country has essentially identical medical standards and practices. It's even harder if you get your degree in a country where the general population has skin darker than Nikki Haley. For most, the main option available to practice medicine in the US involves going back to medical school in the US - even if they've been a practicing cardiologist for the last two decades in their home country.

In short - US doctors don't want to compete with foreign-trained doctors, and the system is set up explicitly to prevent this from happening.

Note we already do this with nursing staff. If you go to lower income countries where english is widely spoken (think the Philippines) the USA draws off a lot of their most experienced and talented nurses. It's not a oneway street as the remittances from Filipinos working overseas contribute a significant fraction of the countries overall economy, but I gather we're still not too popular with hospital administrators over there.

For MDs I think the the board exams, which practicing physicians generally aren't able to pass without taking a lot of time off to restudy the material, plus the requirement to go back through the residency process in the USA along the difficulty of even getting a residency slot as a foreign trained MD, acts as the most significant barrier to bringing in more foreign trained MDs to bring down the cost of healthcare in the USA.

Sol - I generally find your comments to be a very high edition to this forum. But the above is just snarky and mean.

Jokes! Just jokes. I love our Canadian neighbors, their food, their women, their landscapes, their accents, and their civility. And their healthcare. But what kind of neighbour would I be if we couldn't trade a little light ribbing?

The other comments above about non-federal restrictions to importing more medical professionals are well taken, but those rules come from the same slightly racist and overtly protectionist mindset responsible for our immigration restrictions. Doctors know they can command outrageous salaries only as long as they are a scarce resource, so they created barriers to entry in their field. I know other professions have done the same. That doesn't make it right.

And in a moment like this one, when the national conversation centers on improving access and lowering costs for Americans seeking healthcare, I think that reevaluating our protectionist policies is a good place to start.

If you really want to solve this enormous and intractable problem that has so efficiently divided the nation, which has stymied congress and spawned so many pages of this very thread and thousands of others like it across the internet, maybe consider just talking to the AMA about changing those rules?

Also, did sol just make the case for systematically draining talent from other countries at their expense? That's quite out of character.

Yes I did. We do it with programmers and engineers. We do it with agricultural workers, and manicurists, and drywall mudders, and taxi drivers. In previous generations we did it with police officers and nuclear scientists. America was built by stealing the most talented and motivated people from every other country and offering them a chance at a better life here, with more freedoms and more opportunity and hopefully with more prosperity. I see no reason to deny this part of our history. Our diversity is a big part of our success.

So yes, by all means drain those foreign talent pools. They also get to try to drain ours. May the best country win.

I love this talk about cost reduction and doctor salaries. Kudos to everybody. My thoughts are likely very biased considering I get a doctors salary but here are my comments on some of the topics above:

Doctors have the potential to make a high income. Not all doctors. Salaries range by geography and specialty. Some doctors make slightly over $100k while others can make over $1 million. In fact the average income for a physician is under $250k/yr which in my opinion is not to absurd for the education and work that they do (remember I am biased.) Don't forget because of our progressive tax code, making $250k/yr is not twice as good as make $125k/yr. Also doctors pay steep licensing and continuing medical education fees as well as malpractice insurance which lowers that income substantially. Also of note many physicians work well over 40 hours a week. It is not uncommon for 60-80 hour work weeks which allows them to make such a large income. Lastly most physician salaries have gone down comparative over the decades. Cardiologist don't make $800k like they used to. Actually the MACRA reimbursement model has a programed in rise in reimbursement that is below inflation. Which means compensation will continue to decrease as the years go by. I promise you it is not all roses for everyone.

I fully agree that the cost of becoming a doctor is outrageous. It is not uncommon to come out of residency with over $300k+ in school debt. Speaking of education. Many countries have medical school as part of undergrad and then they do a residency. This saves 4 years of education and debt as compared to the US. I'm sure physicians would be more amicable to lower wages if their education was fully funded. And BTW, because of the progressive tax code the interest rate on school loans is not tax deductible.

It is idiotic, but physicians are expected to live the "physician lifestyle." Therefor you can not judge how well a physician is doing financially by the car they drive or the latest vacation they went to. I know plenty of physicians who are broke despite driving a BMW to work every day. Very un-mustachian.

Someone brought up the AMA which in my opinion is a joke and in bed with CMS and lobbyists. They do not advocate for physicians and I refuse to give them money. I doubt anyone can get any positive leeway with that organization.

Regarding foreign doctors: The US has a very robust foreign trained doctor program. Currently 25% of our physician workforce is a foreign graduate. Many are Middle Eastern, Indian, Pakistani and Asian. The only time I have an issue with a foreign doctor is when their English is so bad that their patients have a hard time understanding them. It is rare, but it happens. You can't treat a patient if they can't follow your recommendations. More immigrant physicians would definitely help with the supply demand curve and the free market would lower their compensation naturally over time. For example doctors in NY and California are some of the lowest paid while working in Wisconsin or Alaska they can make a fortune.

TLDR, most docs do not make the crazy income described. This is especially true when considering the amount of overtime they work, their higher tax bracket, their school debt, their malpractice insurance, and all those licensing fees. Also, physician reimbursement has been on the chopping block for decades and continues to go down adding to the burnout and dissatisfaction of our physicians. In reality, to curb the cost of healthcare salaries will also have to go down, but so should education costs, licensing fees, malpractice insurance and maybe even taxes for those who provide unreimbursed care to the poor. I think we want our docs to be compensated well not obscene, but well enough so that bright young minds choose to do medicine instead of wall street.

EnjoyIt, thanks for giving us your physician's perspective on the compensation issue. Just out of curiosity, how much are we talking about on an annual basis for licensing fees, malpractice insurance, and unreimbursed costs of treating indigent patients? I'm sure those costs vary a lot from place to place and from specialty to specialty, but can you give us some ballpark ranges?

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference. Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference. Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

10% is a big chunk...thinking like this is the 'death by 1000 cuts' mentality.

I could say 'oh thats only x% of healthcare costs' for many other things. They add up....

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference. Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

10% is a big chunk...thinking like this is the 'death by 1000 cuts' mentality.

I could say 'oh thats only x% of healthcare costs' for many other things. They add up....

I'd have to agree, assuming the 10% cost stated above is correct. In order to have the US's health care system be more in line with other developed nations, we need to cut per-capita cost by roughly 25-40%.† Obviously we aren't going to have physicians work for free, but a 30% reduction in salaries would get us about 10% of the way to that goal, and would put physicians salaries more in line with what they earn elsewhere. Of course as EnjoyIt and others have noted it would take a wholesale change in the system, including altering the upfront cost of medical school and hours worked.

† The US spent $9,451 per person in 2015; the 'next 9' (all developed nations in Europe) & had a median cost of $5,267 and a max of $7,765. Shooting "low" at a 25% reduction would put costs at $7,088 and leave the US still as the 2nd most expensive (after Luxembourg). A 40% reduction ($5,670 per person) would still leave the US in the top 5 and still way ahead of Canada, the UK and Japan on a per-capita basis. Of course its never an apples-apples comparison due to differences in population, demographics etc but I think those 'goals' are a fair target

We spend $3.2 trillion on healthcare each year. If 10% of that goes to MDs, that's $320 billion. The first estimate I found for the number of active doctors in the USA was about 850,000, or about $375,000 in spending per MD, which seems like it's in the right ballpark once you factor in the cost of fringe benefits (retirement and, or course, health insurance ;-) ). So it seems like the 10% number is plausible.

We spend $3.2 trillion on healthcare each year. If 10% of that goes to MDs, that's $320 billion. The first estimate I found for the number of active doctors in the USA was about 850,000, or about $375,000 in spending per MD, which seems like it's in the right ballpark once you factor in the cost of fringe benefits (retirement and, or course, health insurance ;-) ). So it seems like the 10% number is plausible.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

I almost added this to one of my comments above, but I didn't want to seem like I was endorsing it: I predict that the first target of the inevitable cost reductions in healthcare, when they arrive, will be physician salaries. Though they are a 10% piece of the health care pie, they are a highly visible one. Plus, I think that people tend to direct their ire to the more visible targets that they see all around them (the rich doctor in the gated part of your upper middle class subdivision whose kids go to school with your kids) rather than the more egregious targets they don't have any contact with (the pharma CEO who you never see because he has an army of people to do his errands for him). Also, physicians will be way less organized than the lobbying interests protecting CEOs, hospitals, insurance companies, etc. Don't worry-they'll all be happy to blame doctors to take the heat off themselves.

Physician salaries are higher in the US, and they will inevitably come down. But we can also hope that they come down together with treatment expenditures. Perhaps some doctors will see that their indifference to drug and other treatment prices will eventually lead to outcomes that personally affect them. When you prescribe a drug because you think the pharma rep is hot, and it's 60x the cost of the first line treatment, that serves to destabilize the entire system. Eventually, it will catch up to you. That's not every doctor (and many doctors are wonderful about being honest about the dubious benefits of newer me-too drugs).

Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have. Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.

Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have. Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?

Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have. Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?

Also, why didn't he do this day 1?

Seems like it is about time for someone to test the limits of the executive order in court. Or is that already happening? Seems illogical that EOs can so easily undermine an act of congress like this. But when has our government ever been logical? :-)

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference. Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

10% is a big chunk...thinking like this is the 'death by 1000 cuts' mentality.

I could say 'oh thats only x% of healthcare costs' for many other things. They add up....

Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have. Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?

What this does is allow small businesses and (potentially) individuals to skirt the ACA requirements for minimum coverage (the "essential benefits" listed in the ACA). Once again people will be able to buy health insurance that doesn't cover much and costs less. The fear (shared by most medical insurance companies as well as just about every patient group out there) is that we'll suddenly have lots of these plans available. Health and young individuals will start buying those plans (skirting the insurance penalty for not having medical insurance). This in turn will drive up the cost for those with ACA-style coverage, most notably those with a chronic health condition as well as the elderly, leading to much higher costs for those people (the so-called "rising premium death-spiral").

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Also, why didn't he do this day 1?

Not even god can say why Trump does what he does, but I'm guessing its because thought the GOP, with control of both legislative branches, would unveil the wonderful plan they had been promising for 7 years and get it passed within the first 100 days.

Most medical students go into incredible debt...and even worse debt for specialist training. However, they easily pay that back due to the expectation of large salaries

I don't see this as any different from any other market bubble. Real estate prices are so high because rents are so high! Salaries are so high because profits are so high! Gold is so high because everyone is buying it! It will pop eventually, and not just for doctors. All higher education has to come down in relative price.

And in an interesting twist that is rarely mentioned around these parts, the solution to this thread's problem is already being discussed in other threads: more immigration. Those top notch doctors from Argentina, or Canada, or the UK will work for normal middle class salaries. They are what we need to bring down health care costs in America. Wildly unrestricted immigration policies for anyone with an MD would be a good start. Let's import some of that foreign talent.

Restrictive immigration policies are part of the reason why American healthcare costs so much. We pay our doctors too much, in part because American medical training costs so much. But it's not a chicken-and-egg problem, because we already have access to millions of highly trained (on someone else's dime) medical professionals who desperately want to move to America and work for half of the typical US doctor's wage. All we have to do is stop refusing them permission to immigrate.

Please don't. I work with MDs from other countries who can't practice here because their standard of care is so different than the US. And some of it, yes, would be ok but some of it would cause adverse outcomes.